Basic Information
| Provider Information | |||||||||
| NPI: | 1386842870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PANTHER EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8126 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191018126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003550808 | ||||||||
| FaxNumber: | 2158342862 | ||||||||
| Practice Location | |||||||||
| Address1: | 1395 S PINELLAS AVE | ||||||||
| Address2: | |||||||||
| City: | TARPON SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346893790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7279425002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | PROVASNIK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8003550808 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 38658 | 01 | FL | BLUE SHIELD | OTHER | CG9999 | 01 | FL | RAILROAD MEDICARE | OTHER |